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Stroke rehabilitation in adults | Guidance and guidelines | NICE

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Evidence-based recommendations on stroke rehabilitation for adults

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this seems to be the most up todate version - its HUGE! - i'll upload what seems to be a trimmed down version too

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The effect of a multifaceted stroke telerehabilitation intervention on falls-related self-efficacy and satisfaction with care

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The effect of a multifaceted stroke telerehabilitation intervention on falls-related self-efficacy and satisfaction with care

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Powered wheelchair use as an intervention in stroke rehab

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Powered wheelchair use as an intervention in stroke rehab

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Louise's intervention annotated bibliography

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Components of SSNAP

SSNAP clinical audit

The clinical component of SSNAP collects a dataset for every stroke patient, including acute care, rehabilitation, 6-month follow-up, and outcome measures in England, Wales and Northern Ireland.

National and regional results are available, each with easy access versions for stroke survivors, carers and the general public. Interactive maps of the results are available. New data are published every four months and annually. SSNAP also provides real-time analysis of patient level data for clinicians.

SSNAP acute organisational audit

The SSNAP acute organisational audit is a snapshot audit which runs on a biennial basis, and reports on the structure and organisation of acute stroke services in England, Wales and Northern Ireland. It has achieved 100% participation of acute sites since 2004 and produces information on staffing levels and skill mix, organisation of acute care processes, provision of stroke treatments such as thrombolysis and thrombectomy, access to early supported discharge (ESD) and patient and carer engagement. Results from the 2016 acute organisational audit were published in November 2016.

National and site-level results are available, including "easy access versions" for stroke survivors, carers and the general public.

Post-acute organisational audit

The SSNAP post-acute organisational audit focused on the structure and organisation of post-acute stroke care and reported in 2015. Results for the audit were published in two phases. Phase 1 obtained information from Clinical Commissioning Groups (England), Local Health Boards (Wales) and Local Commissioning Groups (Northern Ireland) on what post-acute stroke services they had commissioned (provided) for patients in their locality. Phase 2 collected data from all identified post-acute stroke services on the make-up of their service, including staffing levels, waiting times, time limits to service and 6 month reviews.

National, regional, and CCG/LHB/LCG level results are available, including "easy access versions" specifically for stroke patients and their carers and interactive maps showing the location of every post-acute stroke service identified.

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Sentinel Stroke National Audit Programme (SSNAP)

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The clinical component of SSNAP collects a dataset for every stroke patient, including acute care, rehabilitation, 6-month follow-up, and outcome measures in England, Wales and Northern Ireland. National and regional results are available, each with easy access versions for stroke survivors, carers and the general public. Interactive maps of the results are available.

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The Sentinel Stroke National Audit Programme (SSNAP) aims to improve the quality of stroke care by measuring both the structure and processes of stroke care against evidence based standards. These standards are informed by the National Clinical Guideline for Stroke, and national and local benchmarks.

Building on 15 years of experience delivering the National Sentinel Stroke Audit (NSSA) and the Stroke Improvement National Audit Programme (SINAP), SSNAP has pioneered a new model of healthcare quality improvement through near real-time data collection, analysis and reporting on the quality and outcomes of stroke care.

https://www.rcplondon.ac.uk/projects/outputs/sentinel-stroke-national-audit-programme-ssnap

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https://www.nice.org.uk/guidance/qs2

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Royal college of Physicians - guideline for stroke

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Royal college of Physicians - guideline for stroke

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Calls for all patients to receive an urgent brain scan within 1 hour of being admitted to hospital, which is a major reduction in the time limit from the previous guidance of 12 hours. The guideline recommends that all acute stroke hospitals have access to brain scans 24 hours a day and calls for local stroke services to be organised to minimise the time to treatment for the maximum number of people.

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Non statutory that is run by young stroke survivors to help young stroke survivors. They offer help through social media, blogs, support groups and support for the family.

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Different Strokes | Stroke Charity Helping Younger Stroke Survivors

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Welcome to Different Strokes - a UK stroke charity providing a unique service to younger stroke survivors and information about stroke in young people.

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Statutory - Stroke specialist nurses seeing all stroke patients when admitted at A&

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Statutory - Stroke specialist nurses seeing all stroke patients when admitted at A&

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Our stroke nurse practitioners are committed to raising standards of stroke care throughout the Trust.

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This is important as after a stroke cognition can be affected . Patients may need a capacity assessment when making decisions about their care - this could directly effect OT intervention

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Social Care Institute for Excellence (SCIE)

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by empowering people to make decisions for themselves wherever possible, and by protecting people who lack capacity by providing a flexible framework that places individuals at the heart of the decision-making process

by allowing people to plan ahead for a time in the future when they might lack the capacity, for any number

Key messages

The Mental Capacity Act (MCA) 2005 applies to everyone involved in the care, treatment and support of people aged 16 and over living in England and Wales who are unable to make all or some decisions for themselves.

The MCA is designed to protect and restore power to those vulnerable people who lack capacity.

The MCA also supports those who have capacity and choose to plan for their future - this is everyone in the general population who is over the age of 18.

All professionals have a duty to comply with the Code of Practice. It also provides support and guidance for less formal carers.

The Act's five statutory principles are the benchmark and must underpin all acts carried out and decisions taken in relation to the Act.

Anyone caring for or supporting a person who may lack capacity could be involved in assessing capacity - follow the two-stage test.

The MCA is designed to empower those in health and social care to assess capacity themselves, rather than rely on expert testing - good professional training is key

If capacity is lacking, follow the checklist described in the Code to work out the best interests of the individual concerned

Understanding and using the MCA supports practice - for example, application of the Deprivation of Liberty Safeguards

Reach

About two million people in England and Wales are thought to lack capacity to make decisions for themselves. They are cared for by around six million people, including a broad range of health and social care staff, plus unpaid carers. Those working in health and social care include: doctors, nurses, dentists, psychologists, occupational, speech and language therapists, social workers, residential and care home managers, care staff (including domiciliary care workers), and support workers (including people who work in supported housing).

A lack of mental capacity could be due to:

a stroke or brain injury

a mental health problem

dementia

a learning disability

confusion, drowsiness or unconsciousness because of an illness of the treatment for it

substance misuse.

Five key principles

The Act is underpinned by five key principles (Section 1, MCA). It is useful to consider the principles chronologically: principles 1 to 3 will support the process before or at the point of determining whether someone lacks capacity. Once you've decided that capacity is lacking, use principles 4 and 5 to support the decision-making process.

Principle 1: A presumption of capacity

Principle 2: Individuals being supported to make their own decisions

Principle 3: Unwise decisions

Principle 4: Best interests

Principle 5: Less restrictive option

Assessment of capacity and best interests decision-making (Sections 2-4, MCA)

What is mental capacity and when might you need to assess capacity?

Having mental capacity means that a person is able to make their own decisions. You should always start from the assumption that the person has the capacity to make the decision in question (principle 1). You should also be able to show that you have made every effort to encourage and support the person to make the decision themselves (principle 2). You must also remember that if a person makes a decision which you consider eccentric or unwise, this does not necessarily mean that the person lacks the capacity to make the decision (principle 3). Under the MCA, you are required to make an assessment of capacity before carrying out any care or treatment - the more serious the decision, the more formal the assessment of capacity needs to be.

When should capacity be assessed?

You might need to assess capacity where a person is unable to make a particular decision at a particular time because their mind or brain is affected by illness of disability. Lack of capacity may not be a permanent condition. Assessments of capacity should be time- and decision-specific. You cannot decide that someone lacks capacity based upon age, appearance, condition or behaviour alone.

The test to assess capacity

Two-stage functional test of capacity

In order to decide whether an individual has the capacity to make a particular decision you must answer two questions:

Stage 1. Is there an impairment of or disturbance in the functioning of a person's mind or brain? If so,

Stage 2. Is the impairment or disturbance sufficient that the person lacks the capacity to make a particular decision?

The MCA says that a person is unable to make their own decision if they cannot do one or more of the following four things:

understand information given to them

retain that information long enough to be able to make the decision

weigh up the information available to make the decision

communicate their decision - this could be by talking, using sign language or even simple muscle movements such as blinking an eye or squeezing a hand.

Every effort should be made to find ways of communicating with someone before deciding that they lack capacity to make a decision based solely on their inability to communicate. Also, you will need to involve family, friends, carers or other professionals.

The assessment must be made on the balance of probabilities - is it more likely than not that the person lacks capacity? You should be able to show in your records why you have come to your conclusion that capacity is lacking for the particular decision.

Best interests decision-making

If a person has been assessed as lacking capacity then any action taken, or any decision made for or on behalf of that person, must be made in his or her best interests (principle 4). The person who has to make the decision is known as the 'decision-maker' and normally will be the carer responsible for the day-to-day care, or a professional such as a doctor, nurse or social worker where decisions about treatment, care arrangements or accommodation need to be made.

What is 'best interests'?

The Act provides a non-exhaustive checklist of factors that decision-makers must work through in deciding what is in a person's best interests. A person can put his/her wishes and feelings into a written statement if they so wish, which the person determining capacity must consider. In addition, people involved in caring for the person lacking capacity have to be consulted concerning a person's best interests.

If a person has been assessed as lacking capacity then any action taken, or any decision made for or on behalf of that person, must be made in his or her best interests

For more detailed information you should refer to the Code of Practice.

Case example: Assessing capacity

Anna Southcott (the patient's name has been changed), 76, has dementia and lives in a care home. She has asthma. Her capacity fluctuates. The district nurse attends to administer flu vaccinations. Ms Southcott is able to communicate.

Principle

The decision relates to administering a flu vaccination. The district nurse should start from the position of assuming that Ms Southcott has the capacity to decide whether to receive a flu vaccination, unless there is evidence to show that she lacks the capacity to do so (principle 1). Even if the nurse has to help Ms Southcott to make the decision, this does not mean she lacks the capacity to make it.

The nurse should not treat Ms Southcott as being unable to make the decision herself until all practicable steps to help and support her to make it have been taken, without success (principle 2). Only if this is the case should the nurse assess Ms Southcott's capacity to make the decision using the two-stage test.

As Ms Southcott's capacity fluctuates, the nurse should consider whether the decision can be postponed until she may have capacity to make the decision. The nurse will speak to Ms Southcott's carers about this, as well as asking about her condition and whether there are any contraindications for a flu vaccination - the following assumes this not to be the case.

Practice

Does Ms Southcott have an impairment of or a disturbance in mind or brain function? There must be an impairment of her mind or some disturbance that affects the way her brain works. She has dementia, so this part of the test is fulfilled to the balance of probabilities (more likely than not).

Does the impairment or disturbance mean that she is unable to make a specific decision, at the specific time she needs to?

The nurse must disregard Ms Southcott's ability to make decisions in general. The impairment or disturbance must affect her ability to make a specific decision at a specific time. The nurse will give her some simple information about why she needs a flu vaccine (her age and asthma), then will ask her to repeat that information. It may be that Ms Southcott has previously expressed preferences about having a flu vaccination, and this might provide a useful steer for the nurse.

In relation to the decision that needs to be made, the district nurse should decide on the balance of probabilities (more likely than not) whether Ms Southcott is able to:

understand relevant information about the decision

retain that information in her mind long enough to make the decision herself

use or weigh up (evaluate) that information as part of the decision-making process.

If Ms Southcott cannot do any of these three things, she is treated as being unable to make the decision.

The decision about Ms Southcott's capacity must not be based merely on her age, appearance, assumptions about her condition or any aspect of her behaviour.

The nurse decides that Ms Southcott lacks capacity to make a decision about receiving a flu vaccination and clearly records her assessment with reasons. Using best interests decisionmaking (principle 4) the decision is taken that in view of her age and asthma, it would be in her best interests to receive the vaccination.

Thanks to Andrew Alonzi of Nottingham Law School for his contribution to this case study.

The new roles, bodies and powers supporting the MCA

Attorneys appointed under Lasting Powers of Attorney (LPAs) - the Act introduces a new form of Power of Attorney which allows people over the age of 18 to formally appoint one or more people to look after their health, welfare and/or financial decisions, if at some time in the future they lack capacity to make those decisions for themselves.

Court of Protection and Deputies - the MCA created a new court and a new public official to protect people who lack capacity and to supervise those making decisions on their behalf. The Court is able to appoint a Deputy, for example, because a person has an ongoing lack of capacity. The Court will tailor the powers of the deputy according to the circumstances of the individual.

The Public Guardian - the role of the Public Guardian is to protect people who lack capacity from abuse. The Public Guardian is supported by the Office of the Public Guardian (OPG). The OPG maintains a register of LPAs and EPAs. It also maintains a register of the Court-appointed Deputies and is responsible for supervising them.

Independent mental capacity advocate (IMCA) - IMCAs are a statutory safeguard for people who lack capacity to make some important decisions. This includes decisions about where the person lives and serious medical treatment when the person does not have family of friends who can represent them. IMCAs can also represent individuals who are the focus of adult protection proceedings. The Deprivation of Liberty Safeguards introduced further roles for IMCA s.

Advance decisions to refuse treatment - the Act creates statutory rules with clear safeguards so that people may make a decision in advance to refuse treatment if they should lack capacity in the future.

A criminal offence - the Act introduces a new criminal offence of ill treatment or wilful neglect of a person who lacks capacity.

Code of Practice

The Code explains how the MCA works on a day-to-day basis and provides guidance to those working with people who may lack capacity. The Code explains the key features of the MCA in more detail, as well as some of the practical steps that people using and interpreting the law need to take into consideration. If you work with people who lack capacity and you are a professional and/or you are paid for the work you do then you have a legal duty to have regard to the Code. It is also relevant to unpaid carers who will be helped and guided by it.

Interface with the MHA

It will be important for health and social staff who support some client groups (for example, those with mental health problems, particularly those with severe and enduring mental ill health, or older people) to have an understanding of the interface issues between the MCA and the Mental Health Act 1983 (as amended by the 2007 Act). This will also include the need to have an awareness of the Deprivation of Liberty Safeguards.

Liberty Protection Safeguards

In July 2018, the government published a Mental Capacity (Amendment) Bill which will see DoLS replaced by the Liberty Protection Safeguards (LPS). This passed into law in May 2019. Under LPS, there will be a streamlined process to authorise deprivations of liberty. Read more here: Liberty Protection Safeguards.

LPS will go live on 1 April 2022

Download

All SCIE resources are free to download, however to access the following download you will need a free MySCIE account:

Available downloads:

Mental Capacity Act 2005 at a glance

MCA e-Learning course: Recently relaunched with CPD accreditation

SCIE has produced a short video to encourage the sector to consider how LPS will seek to promote practice which aligns with human rights and the core principles and duties of the Care Act 2014.

View more: News

All SCIE resources are free to download, however to access the following download you will need a free MySCIE account:

Register now Log into your account

Mental Capacity Act 2005 at a glance

Get SCIELine ebulletin & access all resources. Free MySCIE account

'Clear, informative and enjoyable. Feel much more confident about the MCA'. Nurse advisor.

View more: Training courses

'@SCIE_socialcare sector advice on best interest, mental capacity, DoLS etc are the best resource for these conundrums'. Occupational Therapist.

View more: Case studies

We deliver some MCA training as open courses, designed for individuals or small groups to attend.

MCA training

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by empowering people to make decisions for themselves wherever possible, and by protecting people who lack capacity by providing a flexible framework that places individuals at the heart of the decision-making process by allowing people to plan ahead for a time in the future when they might lack the capacity, for any number The Mental Capacity Act (MCA) 2005 applies to everyone involved in the care, treatment and support of people aged 16 and over living in England and Wales who are unable to make all or some decisions for themselves.

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Non statutory national service that supports people after a brain injury including Stroke including rehabilitation , support groups , careers support and support to integrate back into the community

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brain injury head injury concussion coma traumatic brain injury rehabilitation legal compensation support uk headway

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Headway is the UK-wide charity that works to improve life after brain injury by providing vital support and information services.

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Example of stat service legislation for stroke patients

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Example of stat service legislation for stroke patients

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Stat:
- Health and Social Care Act 2012 states that the care system should consider NICE quality standards in planning and delivering services. An example of a NICE quality standard for stroke patients - https://www.nice.org.uk/guidance/qs2 These quality standards are relevant for OT's because they mention the importance of MDT's and importance of help with returning to work

- NICE guidelines?

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Example of non stat service for stroke patients

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Example of non stat service for stroke patients

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Non stat - an example is the World Stroke Association. It has members around the world which are Stroke Support Organisations (SSO's) and aim to raise awareness of prevention of stroke, treatment and care. They encourage membership from professionals, such as OT's
https://www.stroke.org.uk/sites/default/files/sso_toolkit_eng.pdf

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Stat - required by law. Laws set by the government for public health services to follow. Services paid for and provided by the government.
Non stat - not required by law, but still needed by the public in some situations. They fill the gaps in society and the system. They can sometimes help when NHS cannot fund something, despite it being an important cause. For example, Help for Heroes - supports funding for people coming back from war, and expensive equipment for these people that the NHS cannot fund.
Non stat can even include unpaid voluntary work provided by churches, and help from relatives.

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https://simpleask.net/statutory-and-non-statutory-public-services

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Things required by law but not fully funded by government

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NHS, health care, education, socal wellfare

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An example of a Department of Health strategy to provide a framework for improving quality of stroke services (to include OT services)  

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An example of a Department of Health strategy to provide a framework for improving quality of stroke services (to include OT services)  

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http://www.clahrc-gm.nihr.ac.uk/wp-content/uploads/DoH-National-Stroke-Strategy-2007.pdf

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NHS England to expand provision of 'gamechanging' stroke treatment

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NHS England to expand provision of 'gamechanging' stroke treatment

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https://www.theguardian.com/society/2017/apr/11/nhs-england-stroke-treatment-mechanical-thrombectomy

https://www.england.nhs.uk/2017/04/stroke-patients-in-england-set-to-receive-revolutionary-new-treatment/

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https://www.leedswestccg.nhs.uk/get-involved/we-need-your-views/stroke-services/

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http://www.strokecenter.org/patients/about-stroke/what-is-a-stroke/

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Seems to be more structured than other pathways within the NHS

https://www.england.nhs.uk/rightcare/products/pathways/stroke-pathway/

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https://www.nhs.uk/conditions/stroke/recovery/

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http://www.bbc.co.uk/news/health-12169832

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Channel 4 Documentary

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Can You Rebuild My Brain?: Can You Rebuild My Brain?

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Lotje Sodderland meets neuroscience pioneers who use new knowledge to fix 'broken' brains

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New at home rehab for Stroke survivors in my area

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Stroke patients in Bucks to benefit from new home-based rehab service

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Searching for exceptional people, exceptional care

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More middle aged people having strokes

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The average age of people suffering a stroke for the first time has fallen over the past 10 years, with more than a third happening in middle-age, the latest figures show.

While the majority - 58% - of strokes still happen in older age, 38% occur between the ages of 40 and 69, according to data from Public Health England (PHE).

This is up from 33% in 2007.

The average age for men having a stroke fell from 71 to 68 between 2007 and 2016, while for women it fell from 75 to 73.

Experts have urged people to be aware of the signs of a stroke, as the research shows the condition does not just affect the elderly.

Professor Julia Verne, director of PHE, said: "Stroke is still one of the leading causes of death in England. While it's often associated with older people, the latest research shows that people are having strokes at a younger age.

"Everyone needs to be aware of the signs."

One in six people in England will suffer from a stroke in their lifetime, PHE said, and it is estimated that about 30% of those people will go on to experience another one.

Some 57,000 people in England had their first stroke in 2016, the data showed.

A stroke happens when the blood supply to the brain is cut off, and is the third most common cause of premature death in the UK. There are about 32,000 stroke-related deaths in England each year.

Professor Verne added: "Calling 999 as soon as you see even one of the symptoms develop - in the face, arms and speech - is essential. Speedy treatment will help prevent deaths and disability."

People aged between 40 and 74 have been urged to get an NHS health check to identify if they are at risk of a stroke.

Juliet Bouverie, chief executive of the Stroke Association, said: "We have said time and again that stroke devastates lives in an instant.

"Almost two thirds of stroke survivors leave hospital with a disability, but it doesn't have to be this way.

"The faster you seek and receive emergency specialist treatment for stroke, the better your chances of making a good recovery."

Reuse content

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More middle-aged people are having strokes

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The average age of people suffering a stroke for the first time has fallen over the past 10 years, with more than a third happening in middle-age, the latest figures show. While the majority - 58% - of strokes still happen in older age, 38% occur between the ages of 40 and 69, according to data from Public Health England (PHE).

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Critically ill patients left paralysed by strokes are being "brought back to life" on the operating table by a ground-breaking rapid-response treatment at a London hospital.

Doctors revealed to the Standard that people left unconscious or unable to speak or move by major strokes are making dramatic - sometimes almost instant - recoveries due to the first 24/7 UK centre offering a revolutionary procedure.

Experts say that getting the time-critical treatment within hours after a stroke can be the difference between a full recovery and serious disability or even death.

A girl of 17 was the first to receive the new "gold standard" out-of-hours care at St George's Hospital, Tooting, after being rushed late at night from Surrey when conventional clot-busting drugs failed to work.

She was unable to speak or move one side of her body - but suddenly recovered on the operating table when doctors fed a 3ft-long catheter wire through her groin to "fish out" life-threatening blood clots in her brain.

Consultant neurologist Dr Bhavini Patel said: "The whole of her right side had no power. She was mute.

"As soon as the doctors pulled the wire out, that was it. She was speaking again. I went in to see her and she said, 'Oh, I can move my leg. I can move my arm. I can speak.'

"She went home the next day. This was the week before her 18th birthday."

Dr Joe Leyon, the interventional neuroradiologist who performed the procedure, said: "It's devastating for patients to find one moment they're completely paralysed and/or have lost speech.

Terminally ill man with just weeks to live now 'cancer free'

"It's fair to say they have been brought back to life when they get these functions back in a moment."

The procedure, mechanical thrombectomy, is especially useful in patients with the most severe forms of stroke, including the 10 per cent who fail to respond to clot-busting drugs. These are most at risk of disability or death.

The procedure became an established part of the stroke service at St George's last year after medical research found it more than doubled some patients' chances of surviving without serious disability.

Three months ago the hospital, which features in Channel 4 series 24 Hours In A&E, became the UK's first to offer the procedure round the clock.

Patients are now being rushed from across London and the Home Counties, some by air ambulance, to undergo the procedure to restore blood flow to the damaged part of their brain.

Metal wires barely the breadth of a hair are manoeuvred into the brain and the clot is removed, either by suction or after being trapped in a mesh "basket" and pulled out via veins. Doctors say the procedure lifts St George's acute stroke care from "Premier League to Champions League" status.

Numbers of thrombectomy patients are expected to soar from the current three or four a week as word spreads of its success.

The best outcomes are for patients whose treatment begins within five hours of a stroke. The oldest so far has been aged 90.

Dr Patel said: "If we get them early and they were medically well before, we can make a big difference to them."

St George's already treats 1,200 stroke patients a year, as one of London's eight hyper acute stroke units. These units, set up in 2010, saved 400 lives in their first three years.

Dr Leyon said: "Clot-busting medication is highly likely to fail if the clot is big. The best way to treat these patients is physically to get the clot out.

"What all the studies have shown is that the patient is much more likely to be functionally independent after 90 days if they have this treatment."

'It saved my life'

One patient to receive the new type of emergency stroke treatment at St George's hospital today told how she regained consciousness and began talking within minutes of it being completed.

Teresa Bruce, 67, from Woking, said she was able to go home within two days after undergoing a mechanical thrombectomy to remove three blood clots in her brain. "I just think it's fantastic," she said.

"I wouldn't be here otherwise. It [the stroke] was out of the blue. There was nothing to show why I had a stroke.

"I'm virtually back to 100 per cent. I'm 99 per cent."

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London hospital brings people 'back to life' with new stroke treatment

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Critically ill patients left paralysed by strokes are being "brought back to life" on the operating table by a ground-breaking rapid-response treatment at a London hospital. Doctors revealed to the Standard that people left unconscious or unable to speak or move by major strokes are making dramatic - sometimes almost instant - recoveries due to the first 24/7 UK centre offering a revolutionary procedure.

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BBC Radio  4 - The life in my head: From Stroke to Brain attack

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BBC Radio  4 - The life in my head: From Stroke to Brain attack

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the life in my head: from stroke to brain attack

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The Life in My Head: From Stroke to Brain Attack - BBC Radio 4

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Robert McCrum journeys into his own brain to understand more about his stroke.

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News articles about Stroke Patients (for week 21)

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News articles about Stroke Patients (for week 21)

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Average age of first stroke patients falls (BBC) - http://www.bbc.com/news/health-42871861
Potential council cuts to cut funding for Stroke Association (From my hometown) - http://www.theargus.co.uk/news/15918209.Mum_who_had_stroke_pleads_with_county_council_not_to_cut_funding_for_victims/

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http://www.bbc.co.uk/programmes/b09rdg0z

http://www.channel4.com/programmes/can-you-rebuild-my-brain